EPI 542/GH 562
Epidemiology of TB
Take Home Final Exam
Sami Mushabab Alqahtani
Question 1:
Compare and contrast the important differences in approach in TB control in industrialized/developed countries settings versus low resource/developing country settings. This is one of the major objectives of the course. Why do these differences exist? What are the lessons learned and what specific steps would you propose to diminish the disparities and inequalities? This might include some consideration of differences in diagnostic capacity, surveillance and evaluation, program management, involvement of other sectors, prevention, and use of vaccine. A brief consideration of basic TB epidemiology in each setting would be needed.
Introduction
Global incidences of tuberculosis (TB) have been linked to failed control programs, especially in developing nations. However, this is no longer the case, considering that even countries that have robust control programs still experience high incidences of the disease. Consequently, risk of infections in developed countries may still be high, which can be credited to several factors. Majorly, the migration of people from developing countries to developed ones complicates control approaches that are adopted by the latter. There are differences between developed and developing countries concerning control approaches for tuberculosis, which indicates that each nation has to define its needs in accordance with its epidemiological condition.
Distinguishing Control Approaches of Tuberculosis among Nations
Developed and developing countries suffer similar challenges concerning tuberculosis management. For instance, all children, irrespective of their nationality are vulnerable to the disease, considering their weak immune system (Microbewiki, 2010, p. 2). However, TB in developing countries may also be associated with poverty, malnutrition and overcrowding, which may inform the different approaches that may be employed. Low-income countries may thus suffer high incidences of TB infection, as well as high rates of mortality.
Developing countries need to fight TB by reducing malnutrition among children. This can be through the establishment of mandatory feeding programs in schools. On the contrary, developed nations may focus more on new threats such as controlling migration (Dye & Floyd, 2006, p. 6). Considering that tuberculosis is an airborne disease, it can easily be spread through close contact. When individuals with tuberculosis from developing countries migrate to developed nations, then citizens of the host country may contract the disease. Consequently, developed nations focus more on screening of those individuals from developing countries who are seeking for citizenship. Apparently, multi-drug resistances pose new challenges to control approaches for tuberculosis (Espinal, Laszlo, Simonsen, Boulahbal, Kim, & Reniero, 2001, p. 1294). However, control measures for such a challenge affect developed nations more than developing ones. This is because developing nations focus more on overcoming poverty and malnutrition, which makes children to be vulnerable to the disease (Shingadia & Novelli, 2003, p. 624).
In 2010, an estimated 8 million new cases of tuberculosis were registered in the world (Shingadia & Novelli, 2003, p. 625). This caused the disease to become the second leading cause of death after HIV/AIDs. Experts consider that the adoption of modern tools can ensure the reduction of these deaths. Unfortunately, such new tools can only be accessed by developed nations. New multidrug-resistant TB drugs seem to have stabled deaths, although the drugs are beyond the reach of the citizens from low income countries (Chan & Iseman, 2008, p. 587).
Control measures for tuberculosis in developed nations are influenced by emerging threats. In cities such as Barcelona for instance, bone TB has become rare, and this can be credited to excellent control measures (Millet, et al., 2013, p. 539). The situation is however different for spine TB, because the city has been overwhelmed in controlling this strain of the disease. Apart from this, developed nations have to factor diseases such as HIV/AIDS during treatment. Some tuberculosis patients are likely to be infected with HIV/AIDS. In less developed nations, lack of management of HIV/AIDS may further complicate control approaches for tuberculosis.
A majority of tuberculosis cases can be found in low-income countries because of tobacco and alcohol use. This is in addition to poverty and HIV/AIDS infections. Control measures in such nations focus more on educating the public about the consequences of excessive use of tobacco and alcohol. In this regard, social- economic attributes can be credited to the persistent cases of tobacco in developing nations. Africans are more likely to become vulnerable to drug and tobacco use, and this makes them to be under increased risk of acquiring tuberculosis (Chan & Iseman, 2008, p. 588). Vulnerability may also be envisaged in the fact that Africans can be regarded as an economically impoverished class, and this may make them to live in indecent neighborhoods that are overcrowded. To counter such a menace, governments in developing nations have been focusing more on improving housing to diminish cases of tuberculosis (Millet, et al., 2013, p. 540). Such measures have ensured that inequalities between developed and less developed nations concerning vulnerability to tuberculosis are diminished.
A variety of approaches can be employed in order to overcome the inequalities that exist between control measures adopted by the developed and the less developed countries. For instance, developing countries can subsidize the new multidrug resistant TB to their citizens (Sharma & Mohan, 2006, p. 162). This approach can be quite successful in the management of HIV/AIDS. For instance, the antiretroviral medications for HIV/AIDS seemed expensive for developing nations at the onset. When they were subsidized however, many citizens from low income countries were able access the drugs and this ensured effective management of their situation. Apart from this, there is evidence to suggest that governments in developed nations have been quite effective in controlling tuberculosis because of adequate adherence to treatment (Leung, et al., 2010, p. 287). In developing nations, ignorance has resulted into poor adherence, and this has compounded low completion of treatment. In this regard, civil education and awareness by health providers can ensure that adherence to the drugs and treatment is improved. Experts admit that low devotion to control measures such as adherence to drugs may lead to the development of drug resistance (Millet, et al., 2013, p. 541).
Tuberculosis is likely to affect vulnerable populations such as drug abusers and the homeless (Dye & Floyd, 2006, p. 7). Challenges akin to these are more prone to people living in developing countries. Consequently, control approaches such as fighting drug barons can reduce the prevalence of the disease. Developed nations are less likely to suffer extensively in matters to do with drug challenges. Corrupt networks within developing nations may cause citizens to become vulnerable to the disease. The fight against drug abuse as in the case of developed countries can help diminish the rates of tuberculosis. Drug abuse influences the epidemiology of
tuberculosis, and developed nations have been quite successful in fighting trade in illicit drugs. Apart from this, incarceration, alcohol abuse and tobacco use may increase the risk of developing tuberculosis (Leung, et al., 2010, p. 287).
Considering that tobacco use has been associated with high incidences of tuberculosis, governments have often been focusing on the implementation of restrictive policies. Studies show that consciousness raising campaigns on tobacco use have been effective in stopping excessive smoking in high income countries (Slama, Chiang, Enarson, Fanning, Gupta, & Ray, 2007, p. 1049). Unfortunately, the tobacco industry has shifted focus towards countries that have lower income. This has made citizens in developing countries to become vulnerable to tuberculosis. In order to diminish the inequalities in tuberculosis prevalence, governments in developing nations need to establish such consciousnesses-raising campaigns. Experts believe that a multidisciplinary approach that take into consideration coadjutant factors can help to alleviate the challenge (Millet, et al., 2013, p. 540).
According to world health organization (WHO), only 60% of countries in the world have a notification data that can help them to initiate early detection and diagnosis for cases of tuberculosis that become resistant to drugs (WHO, 2011, p. 4). The organization asserts that most of the countries that have notification data are developed, and this makes the less developed ones vulnerable. To overcome this inequality, it is important to establish efficacious treatment that can allow for adequate prevention. Accordingly, an adequate prevention mechanism that works in tandem with epidemiological surveillance would avoid the transmission of new cases (Dye & Floyd, 2006, p. 7). It becomes apparent to acknowledge that governments in developing nations need to enhance tuberculosis control programs in order to favor and standardize the management of resistant forms of tuberculosis.
Control -based approaches for tuberculosis are dependent on how much resource a country is willing to invest in the fight against the disease (Millet, et al., 2013, p. 539). Tuberculosis requires long-term treatment. Developing nations have high prevalence of cases in which patients abandon the treatment, and this has resulted into the current inequalities. This can be overcome if strong control measures such as active epidemiologic surveillance system are established. For instance, hospital discharges should be controlled to prevent a situation in which patients abandon uptake of drugs while at home because of the fear of long-term treatment (Chan & Iseman, 2008, p. 589). Even if discharges are permitted, tuberculosis program that ensure that public health nurses follow up on patients can help in the completion of treatment.
Considering that incarceration can increase the prevalence of tuberculosis, developing nations may learn from interventions that have been adopted by high-income countries. In Spanish cities such as Barcelona for instance, there existed a strong coordination between tuberculosis programs and prisons (Microbewiki, 2010, p. 4). This approach achieved great success by lowering the prevalence of the disease.
Conclusion
Tuberculosis controls approaches between developed and less developed nations are vast, and this can be credited to the issue of resources. Developed nations have vast resources, and can invest in control measures such as multidisciplinary approaches. Using notification data have for instance helped to ensure early detection and diagnosis of the disease, and this has shielded against drug resistant strains. To overcome inequalities between developed and less developed nations, the latter need to learn from their high income counterparts by managing diseases such as HIV/AIDS, and increasing campaigns against the excessive use of tobacco. Adopting multidimensional approaches as well as educating citizens about the need to ensure the completion of treatment can help to reduce prevalence. Apart from this, tuberculosis may become resistant to drugs, and emerging drugs can become expensive. Governments in developing nations can subsidize drugs to ensure access by low-income patients.
References
1- Chan & Iseman. (2008). Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis: A Review. Current Opinion on Infectious Disease, 21, 587–595.
2- Dye, C., & Floyd, K. (2006). Disease Control Priorities in Developing Countries. Retrieved February 27, 2016, from Ncbi: http://www.ncbi.nlm.nih.gov/books/NBK11724/
3- Espinal, Laszlo, Simonsen, Boulahbal, Kim, & Reniero. (2001). Global Trends in Resistance to Anti-tuberculosis Drugs. New England Journal of Medicine, 344, 1294–1303.
4- Leung, Lam, Yew, Tam, Chan, Law, et al. (2010). Passive Smoking and Tuberculosis. Arch International Medicine, 170 (3), 287–292.
5- Microbewiki. (2010, August 11). Tuberculosis in Children in Developed Countries. Retrieved February 27, 2016, from microbewiki: https://microbewiki.kenyon.edu/index.php/Tuberculosis_in_Children_in_Developed_Countries
6- Millet, J.-P., Moreno, A., Fina, L., Baño, L. d., Orcau, A., Olalla, P. G., et al. (2013). Factors that Influence Current Tuberculosis Epidemiology. European Spine Journal, 22 (4), 539–548.
7- Sharma, & Mohan. (2006). Multidrug-resistant Tuberculosis: A Menace that Threatens to Destabilize Tuberculosis Control. Chest, 130, 162–272.
8- Shingadia, D., & Novelli, V. (2003). Diagnosis and Treatment of Tuberculosis in Children. The Lancet, 3 (10), 624-632.
9- Slama, Chiang, Enarson, Fanning, H., Gupta, & Ray. (2007). Tobacco and Tuberculosis: A Qualitative Systematic Review and Meta-Analysis. International Journal of Tuberculosis Lung Disease, 11, 1049–1061.
10- WHO. (2011). Collaborative Framework for Care and Control of Tuberculosis and Diabetes. Retrieved February 27, 2016, from. World Health Organization. http://whqlibdoc.who.int/publications/2011/9789241502252_eng.pdf